Basic Information

Language

*By providing my phone number, I understand SEIU 775, SEIU, and affiliates may use automated calling technologies and/ or text message me on my cell phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages or HELP to 787753 for more information.

JOIN OUR MOVEMENT

Yes! I want to join with other long-term care workers for a stronger voice for quality care, living wages and good benefits. I hereby request and voluntarily accept membership in SEIU 775 and I agree to abide by its Constitution and Bylaws. I authorize SEIU 775 (“Union”) to act as my exclusive representative in collective bargaining over wages, hours, benefits and other terms and conditions of employment with my current employer(s) and all future employer(s) within the Union’s jurisdiction.

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MAINTAIN OUR STRENGTH

In exchange for obtaining the rights and privileges of union membership, and special benefits through exclusive access to the SEIU 775 Membership Plus Benefits Program, I hereby request and authorize my employer(s) and/or an entity chosen by the Union subject to Section 3 (“Plan for the Future”), to deduct from my wages an amount equal to all Union dues and other fees or assessments as shall be certified by SEIU 775 under its Constitution and Bylaws and to remit those amounts to SEIU 775. This authorization shall remain in effect and is irrevocable for a period of one year from the date of execution and from year to year thereafter, regardless of my membership status, unless not less than thirty (30) and not more than forty-five (45) days prior to the annual anniversary date of this authorization or the termination of the contract between my employer and the Union, whichever occurs first, I notify the Union and my employer in writing, with my valid signature, of my desire to revoke this authorization. SEIU 775 is authorized to use this authorization with my current employer(s) and with any other employer(s) in the event I change employers or obtain additional employment.

I believe everyone should pay their fair share to support our Union’s activities. In order to build a more powerful Union, I hereby knowingly release SEIU 775 and the State of Washington from any future legal claims or liability related to the State’s past collection of agency fees from me pursuant to CBA Sec. 4.1 and/or RCW 41.56.113.

Contributions or gifts to SEIU 775 are not tax deductible as charitable contributions. However, they may be tax deductible as ordinary and necessary business expenses. I acknowledge that failure to pay my dues on a timely basis may affect my membership standing in the Union, as set forth in the SEIU 775 Constitution and Bylaws.

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PLAN FOR THE FUTURE

In the event my employer(s) ceases payroll deductions, and upon the Union entering an agreement with an entity to act as the agent for Individual Providers for voluntary deductions, I authorize that entity to serve as my agent for purposes of deducting and remitting membership dues, SEIU COPE and other voluntary deductions to SEIU 775 pursuant to the authorizations contained herein. I further authorize SEIU 775 to notify that entity of my decision to designate it as my agent for purposes of dues deductions. For the period the entity designated by the Union serves as my agent, I will work directly through SEIU 775 to direct the agent and I authorize the agent to work directly through SEIU 775 to facilitate any and all aspects of the agent’s relationship with me, which shall include but not be limited to having SEIU 775 represent me and my interests during any dispute resolution concerning any claim that may arise between me and the agent, including full settlement of any such claim. The agent designated by the Union shall not serve as my agent for any purpose other than deducting membership dues and other voluntary deductions and remitting those dues and deductions to SEIU 775.

As a benefit of my membership, SEIU 775 will pay the entity to act as my agent. I understand that, notwithstanding the first paragraph of Section 2 (“Maintain Our Strength”), I may terminate my agency relationship with the agent designated by the Union with thirty (30) days’ notice by notifying SEIU 775 in writing via U.S. mail of my desire to do so, but that if I do not pay my dues through a payroll deduction, I will no longer have access to the SEIU 775 Membership Plus Benefits Program.

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PROTECT THE FUTURE

In the event my employer, its agent, an agent designated by me, or an agent designated by the Union, ceases payroll deductions, I authorize SEIU 775 to make withdrawals from my checking or savings account, in accordance with the authorization provided below. SEIU 775 will notify me of the transition to direct pay at the current email or mailing address on file with SEIU 775 prior to initiating the first payment via debit card, credit card, checking, or savings account, as authorized below.

I hereby authorize SEIU 775 to initiate a recurring, automatic electronic funds transfer with my financial institution beginning on the date listed in the transition notice provided to me in order to deduct Union dues at the current rate of 3.2% of my monthly gross earnings from the account referenced below, or an amount of at least $.01 but not to exceed $350.00, on or within 24 hours of every payday designated by my employer. SEIU 775 will notify me of the transition to direct pay at the current mailing address on file with SEIU 775 prior to initiating the first payment from my checking or savings account, as authorized below. The dues amount may change if authorized according to the requirements of the SEIU 775 Constitution and Bylaws or the Service Employees International Union Constitution and Bylaws. If this happens, I authorize SEIU 775 to initiate a recurring, automatic funds transfer in the amount of the new dues amount when notified by SEIU 775 in writing of the new amount and with at least ten (10) days’ notice before the next funds transfer date. In the case of checking and savings accounts, adjusting entries to correct errors are also authorized. I agree that these withdrawals and adjustments may be made electronically and under the Rules of the National Automated Clearing House Association. This authorization shall remain in effect until I send written notice of my revocation of authorization to SEIU 775 via U.S. mail. I acknowledge that failure to pay my dues on a timely basis may affect my membership standing in the Union, as set forth in the SEIU Constitution and Bylaws.

To pay the dues or other amounts indicated above by automatic deduction from my bank account, I authorize my employer, its agent, or any third-party payroll agent, to provide to SEIU 775’s secure payment processor, the information for the bank account (bank account number and routing number) on file with my employer or its agent that I have designated to receive the proceeds of my paycheck via direct deposit. If my employer or its agent makes direct deposit of my paycheck to more than one account, I hereby authorize my employer, its agent, or any third-party payroll agent to provide the information for the account in which my employer or its agent deposits the largest amount of my paycheck. I understand that after SEIU 775’s secure payment processor receives my bank account information, SEIU 775 will make reasonable efforts to contact me to confirm the accuracy of the account information received from my employer, its agent or any third-party payroll agent at least 10 days in advance of making the first electronic funds transfer from my account. I may revoke this authorization to release my bank account information at any time by sending written notification to SEIU 775 by U.S. mail.

Contributions or gifts to SEIU 775 are not tax deductible as charitable contributions. However, they may be tax deductible as ordinary and necessary business expenses.

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Action

Yes! I want to get active in my union.

Yes! I want to hold politicians accountable to working families and I know we can only do that if we stand
together. I hereby authorize my employer, or the agent designated by the Union, subject to Section 3(“Plan for
the Future”), to withhold the indicated amount per month to forward to SEIU 775 (“Union”) as a contribution to
SEIU Committee on Political Education (“SEIU COPE”). If I don’t choose one of the amounts below, or write in a
different amount, I agree to a $10.00 per month deduction. My signature shows that I agree with the terms
below.

In the event my employer, its agent, an agent designated by me or an agent designated by the Union, ceases my
COPE contributions via payroll deduction, I hereby authorize SEIU to initiate a recurring, automatic electronic
funds transfer with my financial institution beginning on the date listed in the transition notice provided to
me in order to deduct from the account designated above in Section 4 (“Protecting The Future”) the dollar amount
checked or designated below (or $10.00 if I fail to check a box or designate an amount) on the day after the
first payday of the month designated by my employer and to transmit to SEIU as a contribution to SEIU Committee
on Political Education (“SEIU COPE”).

This authorization is made voluntarily based on my specific understanding that: (1) I am not required to sign
this form or make voluntary contributions to SEIU COPE as a condition of my employment or membership in the
union; (2) I may refuse to contribute without reprisal; (3) Under law, only union members and
executive/administrative staff who are U.S. Citizens or lawful permanent residents are eligible to contribute to
COPE; (4) the contribution amounts on this form are merely suggestions, and I may contribute more or less by
this or other means without fear or disadvantage from SEIU or my employer; (5) SEIU COPE uses the money it
receives for political purposes – including, but not limited to, making contributions to and expenditures on
behalf of candidates for federal, state, and local offices – and addressing political issues of public
importance. This authorization shall remain in effect until revoked by me in writing to SEIU via U.S. mail.

Contributions or gifts to SEIU COPE are not tax deductible as charitable contributions.

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